Book Book

Surgical Ethics

BMJ 2000; 320 doi: (Published 29 January 2000) Cite this as: BMJ 2000;320:320
  1. R W G Johnson, consultant surgeon
  1. Manchester Royal Infirmary

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    Eds Laurence B McCullough, James W Jones, Baruch A Brody

    Oxford University Press, £35, pp 416

    ISBN 0 19 510347 5

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    Ethics govern the morality and code of conduct of surgeons in clinical practice. Recent astonishing advances in medical technology have opened up new frontiers and created options for surgical treatment that have often led to vigorous debate about what constitutes right and wrong. What is achievable has to be limited by what is acceptable.

    Surgeons have always tried to limit the harm that they do to their patients in extending the healing power of their craft, but historically they have commonly taken unilateral decisions on the acceptability of risks, and patient choices. Current practice must entail sharing the right to make clinical choices with patients, with families, with other physicians, and with the managers of necessary resources. Surgeons, surgical trainees, and medical students in a changing world need a reliable scholarly source to help them chart the shifting terrain of surgical ethics so that they can conduct themselves in a morally responsible fashion in patient care, surgical research, and education.

    This book provides the first detailed text that discusses ethical issues as they concern surgeons in every sphere of clinical practice. The core concepts that relate to the surgeon-patient relationship—such as informed consent, confidentiality, and advance directives—are well discussed. Seven chapters tackle the ethical issues in surgical practice covering a wide range of surgical patients, including emergency, acute, high risk, and the terminally ill. The relationship between a surgeon and patients who are family members or friends is also considered. Many of the ethical arguments are based on North American systems of health care and legal practice, but they can easily be extrapolated by surgeons practising elsewhere to fit their own circumstances. The discussion of informed consent as it relates to a surgeon's personal operative record, specific survival figures for a centre, and surgical risks is important to every practising surgeon.

    Transplantation surgery receives special attention for fairly obvious reasons: the increasing shortage of organs and the new ways being proposed to solve the problem. The use of live human donors for lung and liver, marginal donors, the proposed use of pig organs, and the cloning of organs are all creating ethical problems that need to be addressed. The problems for transplant surgeons posed by the process of informed consent, which often has to be carried out quickly before a transplant, will increase as science continues to change the theoretical into the possible.

    The ethical analysis of the issues of organ allocation—age related criteria, exclusion based on recipient's habits such as alcoholism, changing financial environment, and re-transplantation—is all highly relevant. However, I question the morality of listing only patients who have health insurance on the transplant waiting list but not imposing similar restrictions on live organ donors.

    This book has succeeded in each of its chapters in discussing ethical principles relevant to modern surgical practice. I am particularly impressed by the emphasis on the clinical relevance of the ethical theories. The scope of the ethical issues discussed and the direct relation to the everyday concerns of practising surgeons makes this book interesting reading.


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